Diagnosis: Plaque Psoriasis.
Treatment: Taltz autoinjector (3 pack) 80mg/ ml (milligrams/milliliter).

The insurer denied: Taltz autoinjector (3 pack) 80mg/ ml (milligrams/milliliter).
The denial is upheld.

The member is an adult female with psoriasis vulgaris of the scalp and back who has failed Humira, Cosentyx, Cimzia, and Tremfya, for whom Taltz is requested. She has also failed topical steroids and calcineurin inhibitors.

The health plan should not cover the proposed treatment.
The formulary offers drugs of classes the patient has not yet failed (Otezla, Stelara), whereas Taltz is an IL17 inhibitor and she has failed Cosentyx (also an IL17 inhibitor). Also, there are no contraindications documented for the use of the formulary drugs in classes she has not failed yet. There is no guarantee that any of the medications would work for this member who has refractory psoriasis.